40wks, not engaged, hearing "CPD", elect c/s, first time mom

[CookAMH]

Hi, I'm hoping to get some help for a friend who has contacted me for advice. She is 40weeks with her first child, with midwives at a hospital where she lives.  I am fairly certain all of this is a bunch of bull but hoped for some experienced feedback before I talk to her: late u/s, big baby, she mentioned concerns about significant difference between head/abdomen circumference, concern about potential shoulder dystocia, etc. I KNOW late u/s are THE MOST inaccurate way to determine a baby's size, does anyone have an article I can send her? Then she said that the head is not engaged at 40 weeks, which I don't know much about. I do know that first babies often are engaged well before 40 weeks, but it doesn't seem like they have to be. They said this can indicate true CPD.(??)  I also feel that true CPD can NOT be determined like this on a woman who has never given birth yet.   Midwives and OB are recommending elective c/s (recovery time better than emergency, all that jazz). What is concerning is her Bradley instructor seems to agree with the midwives and OB, so the advice they are getting from those experienced all around them is to choose a c/s.

What can I share with her about these false claims about CPD, shoulder dystocia? I have the article about correct approach to suspected big babies to send her, anything else that might be helpful?  I can't tell her what to do, but she is a woman who would receive correct information and consider it thoughtfully.

[jennybean0722]

Can't wait to see what people say here.   I just had two mommas (I was backup for them) whose babies never engaged and both ended with csections after a trial of labor.  One homebirth, first time mother, the other mother was having her 2nd baby in hospital.  Her first baby was born vaginally but required extensive forceps and suction, etc, came out limp with no vitals and was brought back to life (that was 9 years ago for her). 

So, is this all true???  That if the baby is not engaged there is some issue, possible CPD or is there something else that it could be?

Jenny

[Sijae]

This is really sad :-(  I hate how often I hear of moms being given this kind of terrible advice.  c-sections are significantly more dangerous for both mom and baby than normal vaginal birth, planned c-sections are even worse for babies because they aren't allowed to choose the right time to be born and don't experience the hormones of labor that prepare them for life outside the womb. C-sections effect future pregnancies and in many states would severely limit her choices for the next birth. Telling a first time mom to have a planned c-section because baby isn't engaged should be criminal.

[jennybean0722]

I'm sure we all agree on that here....  To the original poster, she should be allowed to go into labor.  Labor is not dangerous, and if she has problems during the birth, well than that is what the hospital is there for. 

I hope it didn't seem like I agreed with the midwives/docs....I just find it strange that the two moms I know (one more if you count a friend, so 3) whose babies never engaged, and who were allowed to labor, ended up with sections....Why???  Does a baby really need to be engaged before labor starts?  I never thought that was the case....

J

[phathui5]

I'm with Jenny. Her going into labor isn't going to hurt anything.

Does your friend have a doula or someone who is going to be encouraging her during labor? It sounds like the practice she's with is going to be quick to recommend surgery.

[Monkey Keeper]

Originally Posted by jennybean0722 

Does a baby really need to be engaged before labor starts?  I never thought that was the case....

J

Definitely not!  My #3 was nowhere near engaged when labor started.  In fact, I don't think he engaged fully until shortly before he was born--he was badly asynclitic until he wasn't, and I went from 6-crowning in 4 contractions.

It's possible that all the u/s measurements are correct, but there are lots of mommas out there who birth babes with huge heads or big chests or whatever just fine.  I also believe that yes, babies who TRULY are CPD don't engage because baby knows better (but not all babies who don't engage truly are "too big").  Ultimately, I think your friend needs to sit quietly with herself and listen inwardly and talk with her baby.  And then choose the course that gives her peace.  Either wait for labor and have a c/s or wait for labor and birth OR choose to be induced sooner to improve the caregiver climate around her birth.  She shouldn't feel bullied or judged--she needs to choose the course her heart/soul/gut tells her is right.  

You're a good friend to be helping her out.

[MegBoz]

I'm confused by your mention of "difference between head/abdomen circumference." I googled it & found this:

http://findarticles.com/p/articles/mi_m0CYD/is_15_35/ai_64457461/

"Ultrasound measurement of just the fetal abdominal circumference provides a reasonable estimate of the risk for intrauterine growth retardation among term babies when other measures are unavailable"

Are they concerned about fetal development in any way? (I would think IUGR isn't an issue if they're talking big baby.)

Or is this ONLY about elective CS PURELY for "big baby/CPD/Shoulder dystocia"?

If the latter, well, even ACOG doesn't recommend CS for suspected fetal macrosomia!

http://www.aafp.org/afp/2001/0701/p169.html

"Clinical Considerations

The ACOG practice bulletin discusses the following clinical considerations:

...... CESAREAN DELIVERY.

... Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb),"

Furthermore, Late-term US are notoriously inaccurate and can be off by up to 2#!!!

Finally, I've never heard anything of a baby not being engaged at 40W to be a problem at all. Not in the least. As a matter of fact, vaginal exams to assess baby's position (i.e. "station" + or - 3, etc.) as well as cervical dilation & effacement in late pregnancy aren't evidence-based because there's just no need to know that info. The ONLY value in VEs to acquire that info is if you want to get a Bishop's score to consider being induced. But other than that, those three numbers don't tell you anything about when the baby will arrive.

From that same link:

"INDUCTION OF LABOR.

In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor."

Induction is also particularly risky for first-time moms with a CS risk as high as 50%.

I just browsed this but it looks like a good article:

http://www.bellybelly.com.au/articles/birth/small-pelvis-big-baby-cpd

The idea of a CPD diagnosis without labor particularly pisses me off. They are essentially saying, "This baby won't fit through your pelvis." Well ya know what? THEY ARE RIGHT... but the baby is not SUPPOSED TO fit through the pelvis until the woman is in labor. Ugh! & you can help that process along by doing things like being upright, certain movements, and I think even certain pelvic squeezes. 

Unless she had the disease Rickets (which is very rare in the developed world these days), I can't see logic behind a prenatal diagnosis of CPD for a first-timer.

However, if there is any sort of truth to the big baby/small pelvis concerns it is that much more ESSENTIAL that she have good care providers who KNOW the value of movement & upright positions to help her pelvis open. :( The typical American approach to birth could certainly CAUSE CPD to become a reality (leaving those HCPs with a self-fulfilling prophecy, thinking they were right all along, when in reality they failed to take measures to HELP the birth progress naturally.)

Based on what you've already posted, I think it's reasonable to suspect these HCPs don't know the value of proper support in labor to help a pelvis open naturally, so if she doesn't go for the CS, I'd implore her to get a very good, very experienced, very strong-willed doula.

[msmiranda]

What ever happened to MsBlack and mwherbs?  I bet they know the answer to this!  I have heard of this type of thing happening, where the baby doesn't descend, but I can't see what the harm of laboring for a while would be or why the resulting section (if that's what happened) would necessarily be an emergent one rather than just a regular FTP.

[Monkey Keeper]

Quote:

Originally Posted by MegBoz 

I'm confused by your mention of "difference between head/abdomen circumference." 

 

What she is referring to is a baby who is "barrel-chested", as is common in GD babies. IIRC from my personal research a few years ago after my c/s, babies whose chest circumferences are proportionally larger are statistically more likely to experience a distocia than good old fashioned macrosomic babies.  IF that is the case with this baby, IF the late-term u/s measurements are remotely accurate, then it is at least something to consider.

I feel for this poor mama--feeling bullied and frightened by your birth team is no way to await your first baby's birth.  I hope she can find peace.

[riomidwife]

Originally Posted by Sijae  Telling a first time mom to have a planned c-section because baby isn't engaged should be criminal.

I agree although I will say that a floating head at term in a first time does not bode well........Very often there is a reason why the head is not coming down. Not always, but often. Sometimes it's a cord issue, sometimes it's a malposition issue, sometimes it's fibroids, sometimes it's an unknown issue, but the labors are often long and difficult. If there are no other complications, long and difficult may be all that happens, but the baby is at risk of a cord prolapse. In New Mexico, which has generally very reasonable midiwifery practice guidelines, we are not supposed to labor at home with a primip with an unengaged head at term on account of the risk of prolapse, which one midwife did loose a baby to in that exact scenario.

The threat of a big baby though is entirely different. I do think big babies are more likely to get into a wonky position, and that hospitals in general are not very open to the types of things a woman with a big baby might need to do in order to labor normally and push normally. e.g., move unhindered, not be on a clock, push in any position, be in the water, etc.

So, no I don't think this warrants a c/s but there are additional risks in this situation. In the hospital they have the staff and resources to monitor such labors... and if it were me, well, I'd still be at home.

[XanaduMama]

If I were her, I'd start getting daily Chiro adjustments by a practitioner who also knows Webster technique. As PP mentioned, there could be many reasons for baby not engaging, but it would be good to work on fetal positioning and pelvic alignment. She can find a chiro at www.icpa4kids.org

Spinning babies/Optimal Fetal Positioning techniques would be good to focus on too, if she's not already working on this.

[StellaNuova]

Hi - I am not of professional but a slender woman (who gained ~50 lb) with each baby and my babies NEVER engaged till I was in labor, and I have had two vaginal births...planning on the same for number 3 in a few weeks!  My first babe was 7lb 6oz and my second was 8lb 9oz....

[WifeofAnt]

I don't have any information but my DS (all 8 lbs 10 oz of him) was free floating until about 36 hours before he was in my arms.  At my 39 week appointment DS was -3 station.  I'd feel him wiggle down, pop back up, wiggle down, pop back up for weeks beforehand.  I'd get all excited and then he'd be back to floating in a minute or less.  It took a *long* walk the night before my due date for him to get down and stay down and 18 hours after that... labor started.

So if someone tells me in a future pregnancy that a non-engaged baby at 40 weeks is automatic c-section I call BS.

[plantnerd]

My son never engaged either.  I induced with castor oil at 41w5d.  15 hour labor, 3 hours of pushing, finally forced him out with a massive bruise to the side of his head.  Can't remember the correct term (asyc something or other).  He was only 8lb4oz.  Placenta was about done.  Another 30 minutes of pushing and I would've headed to the hospital for a section, no questions asked, please get my baby out of me.

I just wonder if I hadn't induced how long he couldv'e stayed in there with no pressure to the cervix to begin labor, and if he wouldv'e survived much longer.

I guess I would question an elective CS, but on the other hand, who would really choose to go through a full on labor just to get cut in the end?

[Sudonk]

I agree with others that she should be allowed to begin her birth, and see how it goes.  There are many benefits of allowing her birth to begin spontaneously and the fact that birthing is good at preparing the baby for transitioning to life outside the womb should be considered as well.

My first did engage, but just a day or two before his birth began.  Even then it was only after I explained what I wanted him to do and why.  Who knows if he would have dropped prior to labor if I hadn't asked him to?  My second was still free-floating 3 hours after I reached full dilation.  He dropped 8 minutes before his birth, and came out very easily, despite having a hand by his head.

-Susan

[Lisa1970]

It is very normal for the baby to not be engaged yet. She just needs to be patient and let the baby come in his own time. He does not have the same calendar or clock in there with him as she does out there.

[CookAMH]

Thanks for the replies. She wrote back and it sounds like they are going with c/s. I don't think they made the decision easily, but it's still sad. I know she is sad. I wish we were closer in our relationship to engage about it more, but I'm glad she emailed me about it at all.   I am thankful at least that though I concluded differently, she and her husband spent time researching, praying and talking about it. It sounds like the abdomen/head measurements are more concerning, but my thought is, those measurements can be off! And probably are. Oh well. 

[Monkey Keeper]

Thanks for the update, Alicia!  

I had my c/s for similar reasons (there was more to it that I won't go into), and I certainly was sad when I came to that decision.  But after researching and soul searching and praying about it, I truly felt like my baby and my body were trying to tell me something to which I needed to listen. At that point, I made peace with it, and I ended up having a peaceful, positive c/s birth.  I have no regrets to this day, and I wish the same for your friend.

[XanaduMama]

Please update us when the baby is born! I'd be interested to hear if they found a reason for non-engagement, if s/he was large or the other measurements bore out. Hope all goes well for her!

[BabyBearsMummy]

 

Originally Posted by PinkBunch 

Ultimately, I think your friend needs to sit quietly with herself and listen inwardly and talk with her baby.